Ueda 2016 3-glycemic targets & monitoring- adel el sayed

Glycemic Targets & Monitoring

UEDA Diabetes Mini-Course

Aswan Feb. 2016

Glycemic Targets & Monitoring “1”

Agenda

1. Assessment of Glycemic Control

2. HbA1c “Glycosylated Hemoglobin”

3. SMBG ‘Self Monitoring of Blood Glucose”

4. Hypoglycemia

Blood Glucose Targets

TT1 Advise people with diabetes that maintaining an

HbA1c below 7.0% / minimizes the risk of

developing complications.

TT2 A lower HbA1c target may be considered if it is

easily and safely achieved.

TT3 A higher HbA1c target may be considered for

people with co-morbidities or when previous

attempts to optimize control have been associated

with unacceptable hypoglycemia.

GLUCOSE CONTROL LEVELS

TT4 An individual’s HbA1c target should be regularly

reviewed taking into account benefits, safety and

tolerability.

TT5 Treatment should be reviewed and modified if

HbA1c level is above the agreed target on two

consecutive occasions.

TT6 Advise those in whom target HbA1c levels cannot

be reached that any improvement is beneficial.

GLUCOSE CONTROL LEVELS

HBA1c


Aswan Feb. 2016

HbA1c

HbA1c (glycated haemoglobin) provides information about

average blood glucose levels over the last 2-3 months.

This test measures the amount of glucose that attaches to

haemoglobin this depends on how much glucose is in the

bloodstream.

Ideally HbA1c is measured four times per year. If resources are

limited, less frequent measurements are still helpful.

Factors Supporting Use of HbA1C forScreening and Diagnosis

A1c testing does not require overnight fast (Increase rate

of screening during non-fasting hours)

HbA1c reflects long-term glycemic burden (Relatively less

affected by acute (e.g., stress or illness related perturbations in

glucose levels)

Accepted and current guide in management of diabetes

(A1c laboratory methods now well standardized and reliable)

Suadek CD. J Clin Endocrinol Metab 93: 2447–2453, 2008International Expert Committee. Diabetes Care 32 (7):1327-1334, 2009

The Disadvantages Of Hba1c Testing

Higher cost.

Effects of abnormal red cell lifespan.

Possible age and race related disparities.

The various assay interferences.

Rare instances of rapidly evolving type 1 diabetes may take some time to result in a diagnostic HbA1c level and result in a delay in diagnosis.

Limitations in HbA1c Measures

A- Conditions that will shorten red cell lifespan and can result infalsely low HbA1c: Anemia. Hemolysis. B12/folate deficiency. Various hemoglobinopathies.

B- Conditions that will prolong red cell lifespan and can result in false high HbA1c Post splenectomy state. Polycythemia. Some instances of iron deficiency.

Recommendations 2015

Perform the A1C test at least two times a year

in patients who are meeting treatment goals

(and who have stable glycemic control).

Perform the A1C test every three months in

patients whose therapy has changed or who are

not meeting glycemic goals.

Self Monitoring of Blood Glucose(SMBG)

SMGB should be carried out 3 or more times daily for patients using multiple insulin injection or insulin pump therapy

For patients using MNT (Medical Nutritional Therapy) or oral therapy SMGB may be used 2 to 3 times per week to access fasting and postprandial blood glucose.

Continuous glucose monitoring may be used as a tool to lower A1C in patients above 25 years with type 1 diabetes. It may be useful in those with hypoglycemia unawareness or frequent hypoglycemic episodes.


Aswan Feb. 2016


SM1 Self-monitoring of blood glucose (SMBG) should only be

made available to people with diabetes when they have the

knowledge, skills and willingness to use the information

obtained through testing to actively adjust treatment,

enhance understanding of diabetes and assess the

effectiveness of the management plan on glycaemic control.

SM2 The purpose(s) of performing SMBG and using SMBG data

should be agreed between the person with diabetes and the

health-care provider.

SM3 SMBG on an ongoing basis should be available to those

people with diabetes using insulin.


SM4 SMBG should be considered for people using oral

glucose lowering medications as an optional component

of self-management, and in association with HbA1c

testing:

To provide information on, and help avoid hypoglycemia.

To assess changes in blood glucose control due to

medications and lifestyle changes.

To monitor the effects of foods on postprandial

glycaemia.

To monitor changes in blood glucose levels during

intercurrent illness.


SM5 Regular use of SMBG should not be considered part

of routine care where diabetes is well controlled by

nutrition therapy or oral medications alone.

SM6 SMBG protocols (intensity and frequency) should be

individualized to address each individual’s specific

educational / behavioral / clinical requirements,

and provider requirements for data on glycemic

patterns to monitor therapeutic decision making.

SM7 Structured assessment of self-monitoring skills, the

quality and use made of the results obtained, and of

the equipment used, should be made annually.


Ketone Testing

Ketone testing with either urine strips, or blood when available, should be performed:

During illness with fever and/or vomiting.

When blood glucose is above 15 mmol/l (270 mg/dl) in an unwell Diabetic or when persistent blood glucose levels above 15 mmol/l (270 mg/dl) are present.

When there is persistent polyuria with elevated blood glucose, especially if abdominal pain or rapid breathing are present.

Hypoglycemia


Aswan Feb. 2016

Hypoglycemia

Definition Of Hypoglycaemia

The development of autonomic or neuroglycopenic symptoms.

A low plasma glucose (<4.0 mmol/L or 72 mg/dl)

Symptoms responding to the administration of carbohydrate

(Cryer, Davis, Shamoon, 2003)

Risk of hypoglycaemia (1 of 2)

Only those taking glucose-lowering medicines or insulin are at risk

Risk increases with: Not enough carbohydrate consumption Late or missed meal Fasting or malnourishment Too much insulin or insulin secretagogues Prolonged or unplanned activity Risk increases with: Recent severe hypoglycaemia Over-correction with insulin Pregnancy

Risk of hypoglycaemia (2 of 2)

Liver disease or kidney failure

Gastroparesis

Endocrine disease

Hypoglycaemia unawareness

Failure to notice symptoms due to distractions or sleeping

Intensive glucose control

Long duration of diabetes

Other medications/drugs including alcohol

Increased Risk Of Hypoglycaemia

Diabetes Control and Complications Trial (DCCT) Intensively treated group three times the number of severe hypoglycaemic episodes

United Kingdom Prospective Diabetes Study (UKPDS) 30% of intensively treated experienced hypoglycaemia; events rare in the conventional group

(Diabetes Control and Complications Trial, 1993)

(UK Prospective Diabetes Study, 1998)

Hypoglycemia In Older People

Risk of injury from falls May be missed or mistaken for dementia Malnutrition may increase risk of

hypoglycaemia Avoid long-acting sulphonylureas in older

people Repaglinide, acarbose and DPP-IV inhibitors

may be safer options

(Johnson, Brosseau, Sobule, Kolberg, 2008)

Symptoms Of Hypoglycemia

Mild-Moderate

Fear

Anxiety

Affects self-care

Social stigma

Prejudice

Severe

Injury

Seizures

Transient paralysis

Cognitive impairment

Death

Possible Consequences Of Hypoglycaemia

Treatment of Hypoglycemia

Treatment (2 of 2)

Severe

20 g glucose

Glucagon

Intravenous dextrose

Manage seizure - place person on their side if not too agitated

Treatment of Hypoglycemia

Follow-up management

Meal or snack (15-20 g carbohydrate + a protein source)

Next dose taken as usual

Consider reducing insulin

Assess cause

Prevent recurrence

Avoid BG levels < 4 mmol/L (72 mg/dl)

Determine the cause

Other management strategies

Self-management education and supportLong acting analogues instead of NPHRapid acting analogues instead of

regular/soluble insulinInsulin pumpAbdomen provides most consistent

absorption of insulin

(Garg, Gottlieb, Hisamoti, D’Souza, Walker, Izuora, 2004) (Garg, Paul, Karsten, Menditto, Gottlieb, 2004) (Rosenstock, Dailey, Massi-Benedetti, Fritsche, Lin, Salzman, 2005)

Rebound Hyperglycaemia

After nocturnal hypoglycaemia

Hypoglycaemia between 2 - 4 am

Elevated blood glucose in the morning - after 6 am

Treatment options

Decrease evening intermediate-acting insulin

Move intermediate insulin to bedtime if previously taken at evening meal

Change intermediate to long-acting insulin analogue

Increase bedtime snack(Rosenstock et al., 2005)

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Developing Unawareness

Glucagon response often lost with type 1 diabetes

Epinephrine response may be blunted and delayed

Adrenergic symptoms blunted

People with diabetes should learn to recognize neuroglycopenic symptoms

Managing Hypoglycaemic Unawareness

Unawareness is sometimes reversible

Encourage hypoglycaemia-free state

Medical alert identification

Monitor blood glucose before certain activities, such as sports, driving

(Thomas, Aldibbiat, Griffin, Cox, Leech, Shaw, 2007)

(Amiel, 2009)

(Leiter, Yale, Chiasson, Harris, Kleinstiver, Sauriol, 2005)

(Cox, Gonder-Frederick, Polonsky, Schlundt, Kovatchev, 2001)

Summary

Incidence reduced through education, self-monitoring and self-care

Frightening for person with diabetes and family

Often hypoglycaemia can be prevented Must be addressed at every visit to

healthcare professional Treatment must be revised if recurrent

(Canadian Diabetes Association, 2008)

Lastly we hope that course will achieve

its goals and help you all in getting the

best of the forthcoming conference

UEDA Board


Aswan Feb. 2016

Ueda 2016 3-glycemic targets & monitoring- adel el sayed

Health & Medicine

Transcript of Ueda 2016 3-glycemic targets & monitoring- adel el sayed